In the early 1980s, doctors at Chicago’s Cook County Hospital faced an alarming trend: Thousands of patients from across the city were being transferred to the county facility, including patients whose conditions were unstable, making the transfers medically risky. Many patients ended up in the intensive care unit; others died.
Several years later, the New England Journal of Medicine published a study confirming that transfers had skyrocketed from roughly 1,300 in 1980 to nearly 7,000 in 1983. The study supported what doctors had observed, according to the Chicago Tribune: “that private hospitals in the area are shirking their duty to provide care to the needy.” Reviewing some 500 transfers from private medical facilities to the Cook County hospital over a one-month period, the study found that the vast majority of patients were unemployed, and many had been transferred because they lacked the means to pay for health care. Eighty-nine percent were Black or Hispanic, 24 percent were medically unstable, and just 6 percent had consented to transport.
The Chicago doctors weren’t alone. Across the country, the transfer practice, known as “patient dumping,” had become a serious problem, especially for those in labor. “This was a full-term baby who would have been alive right now if the system hadn’t shuffled the mother around,” one doctor told the San Francisco Examiner in 1985 about a patient in labor who arrived at an Oakland hospital after being turned away from two other facilities. The baby was stillborn. “When she walked in here, I knew immediately something was really wrong,” the obstetrician said. “She was doubled over, holding her belly.”
The problem became so grave that Congress stepped in, passing the Emergency Medical Treatment and Active Labor Act, known as EMTALA. Still in effect today, the law is straightforward: It requires all hospitals that receive certain federal funds to conduct a medical assessment of every patient who shows up at the ER and, in a medical emergency, provide necessary stabilizing treatment. The law defers to medical professionals to determine when a medical emergency exists and what stabilizing treatments are needed.
EMTALA operates as a “point of rescue,” said Nicole Huberfeld, a professor at Boston University’s schools of law and public health. “It is the one law that we have that makes it so that anyone can get access to care when they’re having a medical emergency.”
For nearly 40 years, necessary stabilizing treatment under EMTALA has included abortion care. In July 2022, weeks after the U.S. Supreme Court overturned the right to abortion in Dobbs v. Jackson Women’s Health Organization, the Department of Health and Human Services posted a memo reiterating hospitals’ obligations under EMTALA. When a state had banned abortion but abortion was the stabilizing treatment a patient needed, the memo stated, EMTALA preempted the state law.
In a letter accompanying the guidance, Health Secretary Xavier Becerra assured providers that EMTALA “protects your clinical judgment and the action that you take to provide stabilizing medical treatment to your pregnant patients, regardless of the restrictions in the state where you practice.”
But in a case pending before the Supreme Court, scheduled for oral arguments on April 24, Idaho claims that abortion is not protected under EMTALA, and that the federal government is interfering with state’s ability to ban the procedure. “The whole point of Dobbs was to restore to the states their authority to regulate abortion,” lawyers with the far-right Alliance Defending Freedom, who are representing Idaho, wrote in their brief. “Yet the administration seeks to thwart Idaho’s exercise of self-government on this important topic.” The claim that EMTALA covers abortion, they wrote, “is imaginary.”
If the court were to accept Idaho’s recasting of EMTALA, the safety-net law meant to eliminate discrimination in emergency medical care would be nullified, experts say, singling out pregnant people as a separate and unequal class of patients. Such a ruling would hobble the ability of medical professionals to respond appropriately to emergencies and encourage a new generation of patient dumping.
“Idaho’s arguments would make pregnant people second-class citizens in emergency rooms,” said Alexa Kolbi-Molinas, deputy director of the reproductive freedom project at the American Civil Liberties Union. “That’s the exact evil that Congress was trying to stop.”
(Photo by Drew Angerer/Getty Images)
Photo: Drew Angerer/Getty Images
In the aftermath of the Supreme Court’s decision to overturn Roe v. Wade, near-total abortion bans quickly took effect in several states, including Idaho, where the so-called Defense of Life Act bans all abortions save for those necessary to prevent the death of the pregnant person. During a legislative hearing on the measure in 2020, the law’s sponsor, state Sen. Todd Lakey, said the law included no exception for the broader health of the pregnant person because that was not as important as the life of the fetus. “I would say it weighs less, yes, then the life of the child,” he said.
“If we’re talking health of the mother, that’s a nuanced decision that could be something much less than life,” Lakey said. “If the decision was based solely on a question of some type of health, then you’re talking about taking the life of the unborn child, so that weighs more heavily than simply ‘health.’”
Idaho’s ban has placed health care providers in a precarious position. Violations of EMTALA’s mandate can result in hefty fines for doctors and hospitals and the loss of federal funding that facilities use to treat elderly patients and people with disabilities. Doctors who violate Idaho’s abortion ban, meanwhile, face criminal prosecution, two to five years in prison for each offense, and loss of their medical license.
The narrowness of the exception to Idaho’s ban prompted the federal government to sue the state in August 2022, arguing that the law impermissibly conflicts with EMTALA’s requirement that providers treat “emergency medical conditions,” not only those that pose “risks to life,” but also conditions that place a person’s health in “serious jeopardy.” The text of EMTALA clearly states that where conflicts with state law exist, the federal law takes precedence.
The government asked a federal district court to immediately block Idaho’s law from taking effect while the lawsuit was ongoing. The court agreed, enjoining the Idaho ban “to the extent that statute conflicts with EMTALA-mandated care.”
Idaho appealed the ruling and lost, prompting the state to ask the Supreme Court to intervene, which it did in January, lifting the district court injunction and scheduling the case for oral arguments.
In legal filings, Idaho points out that the word “abortion” is not included in the EMTALA statute, claiming there was no understanding that Congress meant to include abortion care among potential stabilizing treatments required under the law. In contrast, the statute does include the phrase “unborn child,” which according to the state, means that the well-being of the fetus must be weighed in addressing medical emergencies.
Idaho law doesn’t conflict with EMTALA at all, the lawyers argue, because Idaho regulates the practice of medicine in the state. EMTALA only requires doctors to provide stabilizing treatments that are “available” at a given hospital, and since abortion is illegal, it is thus unavailable. And because abortion is unavailable in Idaho, a hospital could legally transfer a patient somewhere else for care, presumably without being accused of dumping. Practically speaking, that would mean coordinating a transfer to a facility out of state and hours away.
Idaho claims the Department of Health and Human Services’ 2022 guidance was merely an attempt to legalize all abortion in the state. “A patient who wanted, but was denied, an abortion cannot wield EMTALA to force an emergency room to perform one,” reads the lawyers’ Supreme Court brief.
Huberfeld, the health law expert, who along with several other legal scholars filed an amicus brief supporting the federal government’s position, says Idaho is misinterpreting the law. EMTALA doesn’t contain the word “abortion” because, at the urging of medical professionals, Congress left the menu of stabilizing treatments to their discretion. At the time of EMTALA’s passage, abortion was protected care, and even states that had banned the procedure later in pregnancy included exceptions for the life and health of the pregnant person. Physicians have long “acknowledged their statutory obligation to provide abortion care in those rare emergencies in which terminating a pregnancy is the necessary ‘stabilizing’ treatment,” Huberfeld and her colleagues wrote.
The reference to an “unborn child,” meanwhile, is defined in the EMTALA statute — just not in the way that Idaho claims. “Three of the four mentions are specifically about taking into account the risks to the unborn child during labor when transferring a patient to another hospital,” said Kolbi-Molinas of the ACLU, which also filed an amicus brief in support of the federal government. The fourth mention is meant to ensure that a pregnant person in the ER will receive care for a pregnancy-related problem that is not currently placing their own life at risk. “So the hospital couldn’t say, ‘Well, you’re fine, so we’re just going to let your baby die,’” Kolbi-Molinas explained.
Those references are important, according to Huberfeld, because before EMTALA, hospitals were abandoning pregnant people in alarming numbers. “There were so many instances of people in labor being turned away from emergency departments and they and/or their newborns dying,” she said. “It was specifically addressed because the circumstances of patient dumping for people in labor were so egregious.”
For Idaho to suggest that Congress actually meant to shield hospitals from having to address the medical needs of pregnant people in favor of protecting the fetus “is like gaslighting,” Kolbi-Molinas said.
And the argument that state hospitals don’t have to provide emergency abortion care because Idaho regulates the practice of medicine turns EMTALA on its head. Huberfeld thinks the argument is bait meant to attract justices inclined to embrace the notion of state sovereignty. EMTALA is connected to Medicare funding, she explained, but hospitals have the option to decline this funding. If they do accept it, there are conditions attached, including EMTALA’s guarantee of non-discrimination. The law was created to establish a national standard due to states discriminating against patients, resulting in unequal care. This state variability often leads to poorer health outcomes for specific populations.
Since the Roe v. Wade decision, instances of women being denied abortions during medical emergencies have become distressingly common, highlighting that the limited exceptions in state bans are insufficient for the safety of pregnant patients.
In Texas, stories like Amanda Zurawski’s, who faced life-threatening situations due to the state’s abortion ban, have drawn attention to the need for clarity in these laws. Zurawski and others have filed lawsuits seeking to clarify the exceptions in Texas’s ban, as well as participating in an amicus brief in the EMTALA case.
Texas has been actively resisting EMTALA protections and even sued the federal government to limit these protections. Despite the government’s response that the guidance merely reinforces existing law, the federal courts in Texas sided with the state, potentially impacting the full protection of EMTALA.
The broader political climate in Texas and Idaho is creating a culture of fear among medical professionals, with threats of prosecution for providing abortion care and increasing restrictions on reproductive health care. This environment is leading to the denial of EMTALA protections for pregnant patients, resulting in discriminatory care and endangering lives. “It’s simply not sustainable.”
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